Quality & Documentation For Heart Failure & AMI Programs

1. Quality & DocumentationFor Heart Failure & AMI Programs Nathalie De Michelis, Cardiovascular Program Manager July 24th, 2014

2. Heart Failure ProgramInpatient and Outpatient FY 2013-2014 • Formal outpatient HF Clinic program • 1535 HF clinic visits • 551 single pts Discharge Unit & Services • for Primary HF Dx • Inpatient visit volume • 174 PDx of AMI • 254 PDx of HF • 254 with 2nd Dx w/ Acute HF

3. ED triage (CP unit, CP/AMI & HF Algorithms) Identifying patient population/AMI & HF program introduction Multidisciplinary Clinical Pathways HF & PCI EBT Cardiology Order Sets Please try to use A fib, AMI, CP, EP, HF, Cath, PCI Initiation of patient education process by HF NP & HF Coach State-of-the-art diagnostics Collaborative input for advanced treatments: interventional, device, surgical therapies, cardiac anesthesia Comprehensive discharge plan/case mgmt f/u with in a week, Home Health when eligible,…. Palliative care/end of life Research pool CV Program Design…Coordinated Care Across the Continuum(In-patient)

4. UCI Cardiac Rehab Cardiology Clinic General Cardiology EP/Pacemaker Clinic Valve Clinic Woman Card Clinic Adult Congenital Clinic CV Preventive Clinic HF Clinic Open access & program follow-up Timely post-discharge HF recommendations to PCP HF Program f/u of moderate-advanced HF IV Lasix 48 hrs and 1 month follow-up phone calls  to prevent ED Readmit HF & DM Chronic Disease in person Coach Care Palliative Care Collaboration soon…HF/Palliative clinic Research pool CV Program Design…Coordinated Care Across the Continuum(Out-Patient)

5. HF & AMI List • HF/AMI List • Communication tool, between the HF Program Manager & the care team, to assist with the identification & the care of this population • Let me know if patients need to be added or deleted from the list below. • Please clarify pink areas on the patient list • Memorandum of Agreement between IM & Cardiology for HF for Heart Failure Patients • New Onset HF Admit to Card Service • Acute HF following in UCI Card Admit to Card • Other Acute HF  request a Card consult

6. Quality Initiatives • Joint Commission Certified HF Program since 2008 • Dr. D. Lombardo Medical Director • OC Cardiovascular Receiving Center since 2005 • Dr. P Patel Medical Director • Multiple National & State Quality Initiatives • American Heart Association (Gold Plus HF AHA award) • American College Of Cardiology • CMS & Joint Commission Measures • Readmission Reduction Task Force • DSRIP projects • Improvement of Primary Care in HF & DM Disease management • Research

7. What are Hospital Quality Measures • Measures based on: • Scientific evidence • Reflect guidelines • Standards of care or practice parameters • Converts medical information from patient records into a rate or percentage that can be assess

8. Why quality measure are important? • Use to assess: • How well care is provided to our patient • Our performance over time • Helps improve patient care • Benchmark for outcomes & resource utilization • (Internal, External , Public) • Public Reporting • CMS & The Joint Commission • Healthcare consumerism • CMS.gov (Hospital Compare), Healthgrades.com, WebMD.com, State organizations • Pricing, Payment and Contracting • Quality data used by insurers in negotiating contracts • Rate affect Reimbursement rate • Pay-for-performance, VBP, Readmission Reduction Program • Physician Quality Reporting System (PQRS), HEDIS

9. AMI Hospital Quality Measures - CMS, TJC • Outpatient Arrival time to ECG & Troponin for CP • Aspirin within 24 hrs of Arrival (or clear documented contraindication) • PCI Within 90 Minutes of Arrival for STEMI • Fibrinolytic within 30 Minutes of Arrival for STEMI (not used at UCI) • Discharge on (or clear documented contraindication if not) • Aspirin • ACE or ARB for LVSD • Beta Blocker • Statin • AMI 30 days Mortality rate • AMI 30 days Readmission rate

10. AMI Composite

11. AMI 30 Day Readmission rate

12. Hospital compare for AMI- PCI & ASA-CP measures http://www.medicare.gov/hospitalcompare/search.html

13. Hospital compare - HCAHPS

14. HF Hospital Quality Measures % of HF patients given: • Discharge Instructions (need all 6 items) • Diet  Cardiac diet  be more descriptive – i.e. 2g low salt, low fat…. • Activity level • Daily Weight Monitoring  Even if on Dialysis • Medications (complete reconciliation w/home & hosp. Rx • with indication for each Rx (NEW TJC measure) • Symptom management • Recommend pt to call if weight gain is >3lbs in a day or > 5lbs in a week • Follow-up appointment (with date and time on DC Instruction) • Documentation of LVS function • ACE or ARB for LVSD at discharge (or clear documented contraindication) • HF 30 days Mortality rate • HF 30 days readmission rate

15. HF TJC & AHA GWTG Measures • DVT Prophylaxis while in hospital • Prior to Discharge on (or clear documented contraindication if not) • Pneumococcal Vaccination • Influenza Vaccination During Flu Season • ICD Placed or Prescribed • For EF≤ 35 (exclude new onset): • ICD Placed or Prescribed • CRT-D or CRT-P Placed or Prescribed if QRS ≥120 or QRS ≥ 150 or LBBB • Discharge on (or clear documented contraindication if not) • Evidence-Based Specific Beta Blockers for LVSD (Bisoprolol, Carvedilol, Metoprolol CR/XL) • Aldosterone Antagonist • Anticoagulation for Atrial Fibrillation • Hydralazine Nitrate ( for African Americans on OGMT) • Post Discharge Appointment (including date, time, location; or home health visit) • Follow-Up Visit Scheduled Within 7 Days or Less

16. HF Hospital Quality Measures – HF Composite

17. Hospital compare for HF

18. GWTG Achievement & TJC Measure – Evidence-Based Beta Blockers [TJC Target 90%] [GWTG Target 85%]

19. GWTG Achievement & TJC Measure – Aldosterone Antagonist for LVSD at DC [GWTG Target 75%]

20. GWTG Plus Quality Measure Anticoagulation for A. Fib [GWTG Target 75%]

21. GWTG Achievement Measure Follow-up at Discharge (with date, time & location) [Target 85%]

22. HF 30 Day Readmission rate

23. How to improve HF/AMI measures & outcomes?

24. How to improve HF/AMI measures? • Treating all present health issues • Make sure well compensated when DC • Education during hospital stay-Patient should be familiar & competent with: • Condition • Medication • Symptom Management • Life style change • Importance of follow-up ( to prevent no show) • Proper Documentation of Guideline therapy • or explicit contraindication • i.e. ACE & ARB contraindicated at this time due to worsening renal function • i.e. Not on anticoagulation for A. Fib due to active GI bleeding • Proper Documentation of conditions & procedures • as it affect Coding

25. How to improve HF/AMI measures? • Use Disease Specific Order Set • Proper Discharge • Medication Reconciliation • All needed components are on Discharge instructions • The discharge summary document must contain • Provider contact information • Discharge date • Discharge Diagnosis • Updated summary of the patient’s hospitalization. • Pending labs, test and imaging • Other follow-up issues for next provider • Complete set of discharge instructions

26. Discharge Process • Proper transition of care • Early follow-up (7 days post dc with PCP & needed specialties) • Give Date & time of appointment before discharge • Prompt transfer of hospitalization information • to PCP or to next care provider • Access to care and medication • Refer to Home Health, Cardiac Rehab, Telemonitoring • Refer to free UCI Patient education classes. • HF, Heart Diet, DM, HTN • The discharge summary creates the Discharge instructions • Be certain the nurse provides the patients with the FINAL version • must notify nurse if there are any last minute changes • Go over the instructions with the patient/family • Fax/e-fax/mail discharge summary to the next care provider

27. Discharge note –Core Measures Memory Aids & Last chance to meet measures Please complete on all AMI & HF (chronic or acute)

28. Memory Aids

29. Memory Aids

30. UC IrvineHealthThe importance of Clinical Documentation

31. Why should we care? • Documentation drives: • The levels of coding, billing and reimbursement • Measure Compliance • Severity of Illness (SOI) and Risk of Mortality (ROM) • Measures by which healthcare organizations & healthcare providers are evaluated and ranked • Stay competitive in the market • Insurance Companies’ Contracting • General public shopping for care • Due to trend of greater transparency & availability of clinical performance data, on internet websites (e.g. Healthgrades, hospital compare) • Prevention of random audits by the government • and serves to support the care provided by a healthcare provider in such an event • Reduce liability in the event of legal action

32. Surfing for Quality of Care and Prices • http://hospitalcostcompare.com • Hypertension Without Major Complications

33. Hospital & Physician Report CardsHealthgrades.com Medicare.gov/hospitalcompare

34. One thing leads to the next • Documentation • ICD Code • DRG (Diagnosis-Related Group) • Severity adjusted DRG • Severity of illness & Mortality data • Outcomes + Accurate Documentation = Quality Observed mortality Expected mortality (From severity adjusted DRGs)

35. What is a DRG and how does it work? • Identifies the "products" that a hospital provides • DRGs have been used in the US since 1982 to determine how much Medicarepays/reimburses the hospital for each "product“ • It is similar to a known recipe: • Each DRG has a relative cost weight & expected LOS

36. DRGs • DRGs that are associated with a higher frequency of mortality are frequently under documented in regard to severity of illness • i.e. heart failure, pneumonias, urinary tract infections, & malignancies • Example: • Patients have who that have respiratory failure and cardiac arrest • Most go into Hypotensive shock and have com. respiratory failure • So if would document these • itwould change the MS-DRG • and improve predicted mortality measures • Inherently, the MSDRG system penalizes rushed documentation

37. SOI, ROM, CC & MCC • Every patient we treat get assigned a SOI & ROM rate based on the documentation between 1 and 4 . • -1: Minor - 2: Moderate -3: Major -4: Extreme • Secondary Diagnosis Coding Rule and impacts: • DRG Assignment, Severity of Illness/Risk of Mortality Reporting; and Organization and Physician Profiling, evaluation and ranking. • Documentation of Diagnosis with severity (Acute, Acute on Chronic or chronic) instead of signs and symptom • assist with CC/MCC, SOI & ROM • Important to document in detail the CCs • All co-morbidities (Condition present on admission) • All complications (Condition that develop after admission)

38. Cardiac Diagnosis(Dx with** are not counted if patient expires)

39. Respiratory Diagnoses(Dx with** are not counted if patient expires)

40. Case Example 55 y/o female LOS 11 days - expired When ≥ 3 different organs are affected  start to see MCC

41. Heart Failure DRGs Comparison

42. 3MMS DRG 285 AMI, expired w/o CC/MCC Dx suggestion to consider M= Affect DRG S=Affect Severity R=Affect Mortality

43. MSDRG are assigned a mortality risk model • Using specific variable descriptions • The mortality is than calculated and give us: • our expected morality rate versus actual observe mortality • The goal is to have high expected rate for low observe rate • This rate is used in our data and benchmarking

44. Case example risk model 901: • Assigned MSDRG of 285- AMI, expired without Comorbidity or Complication (CC)/Major CCMortalitymodel 901

45. UCI Q1 2014 Clinical Outcome reportRisk-Adjusted Mortality

46. AMI case exampleOriginal attestation sheet SOI of 3 and ROM of 3 (Major) DRG 285 - Acute myocardial infarction, expired w/o CC/MCC DRG payment $9117.25

47. Documentation correction • Patient chart documentation improvement that affects SOI & ROM: • Pleural effusion only (would affect SOI) • Add Acute Diastolic Heart Failure (would give it a CC, and affect DRG, SOI & ROM) • Intubated • Instead on a mechanical ventilator (would give it a MCC) • Fluid overload & Hyperkalemia • InsteadFluid & Electr Disorders (hyperkalemia) (would affect ROM) • Also to affect DRG, SOI &ROM Prior to arrest could document: • Com Respiratory failure • Hypotension shock • Coma

48. Coding attestation post documentation SOI of 4 and ROM of 4 (Extreme) DRG 283- Acute myocardial infarction, expired w MCC DRG payment $22597.06 (+ $13479.81)

49. Documentation & coding • Coders are limited in what they can code • They are not allowed to “interpret” • i.e. Hgb 5.0 ≠ to anemia • Document anemia with specific type, acuity & cause • V Fib, Chest compression, defibtillation, epi …Cardiac arrest/Code • Bacteriemiasepsis • No response no noxious stimuli Coma • Document suspicions to the highest degree known • Fail documentation often happen when unable to obtain a test or specimen • Document what the treatment is based on the clinical picture • I.e “Suspect G-pneumonia, ….Rx.. given, as unable to obtain a sputum specimen.” • Do not under-state discharge diagnoses

50. Heart Failure Documentation • r/o differential diagnosis if n/a anymore • i.e. COPS vs HF VS PN. HF is or is no longer the differential diagnosis for SOB/Volume Overload • “Likely”= possible coding of that condition • Determine if it is Right or Left Heart Failure • RHF= gets coded as 428.00 Unspecified HF , no code exist for RHF • Document cause of RHF i.e. RHF 2/2 CorPulmonale • iF RHF alone need to meet all measures